Overdiagnosed by H. Gilbert Welch M. D. & Lisa M. Schwartz M. D. & Sean Runnette

Author:H. Gilbert Welch M. D. & Lisa M. Schwartz M. D. & Sean Runnette [D., H. Gilbert Welch M. & D., Lisa M. Schwartz M. & Runnette, Sean]
Language: eng
Format: epub
ISBN: 9781616579913
Publisher: HighBridge Audio
Published: 2012-09-11T00:00:00+00:00

Table 8.1 A Decision Aid for Men Considering Undergoing Screening for Abdominal Aortic Aneurysm

Screening reduced the five-year probability of dying from a ruptured aneurysm by almost half. But because that probability was low to begin with, only 1.5 men per 1,000 screened experienced this benefit (3.4 – 1.9). And screening had no effect at all on the overall risk of death, which was the same in both groups.

For every man who avoided an aneurysm death because of screening, three were treated for naught—in other words, underwent surgery unnecessarily. As always, surgery poses harm, such as heart attack, blood clots, and potential damage to the circulation to the legs, kidneys, and intestines. Of course, some portion of those three may benefit at some point beyond five years (the life expectancy of a sixty-five-year-old is about seventeen years), so there’s no way to be certain whether they were overdiagnosed or not. At the same time, more than 5 percent of men who were screened were told that the aorta was abnormal but not sufficiently so to require immediate surgery. Instead, they were informed that they needed surveillance, or follow-up testing, possibly for years. Some of these men will eventually be told they need surgery. So there is likely to be more overdiagnosis to come.

How would you react to being told you have an aneurysm but one that’s not yet serious enough to require surgery? What is it like to undergo surveillance every six months, say, over many years? Men contemplating screening should know about the anxiety experienced by this group. One of my vascular surgery colleagues, Brian Nolan, interviewed thirty-four men undergoing surveillance at our center and found that many do worry: 7 percent of men reported difficulty falling asleep, 25 percent felt overwhelmed, and 48 percent reported unwanted thoughts about the aneurysm. But how some men really feel about knowing they have an AAA (and undergoing surveillance) is best communicated using their own words: “Daily I feel as though little to nothing is being done for my condition”; “My family is much more concerned with it rupturing than I am. They treat me like I’m an invalid and won’t let me lift anything”; “I don’t let my grandchildren sit on my lap”; “I feel like I am carrying a bomb that could explode at any time.”

There’s no right answer. AAA screening will help a few, but will lead many more to worry needlessly.

Common medical practice in the United States now includes screening for all sorts of disorders. It is a natural extension of the zeal for early diagnosis. More and more people are told they—or their babies—have abnormalities. Of course, some are helped. But sometimes we know that the number who benefit from screening is extremely small, and sometimes it is so small we can’t even measure it in large studies involving tens of thousands of patients. More often we are not sure if screening has any benefit at all. But we persist on focusing intently on early diagnosis and quite often fail to consider overdiagnosis.

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